Provider Demographics
NPI:1013939602
Name:STEVEN J. DISANTI D.O. S.C.
Entity Type:Organization
Organization Name:STEVEN J. DISANTI D.O. S.C.
Other - Org Name:D/B/A GENOA MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DISANTI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:815-784-5188
Mailing Address - Street 1:109 S GENOA ST
Mailing Address - Street 2:
Mailing Address - City:GENOA
Mailing Address - State:IL
Mailing Address - Zip Code:60135-1120
Mailing Address - Country:US
Mailing Address - Phone:815-784-5188
Mailing Address - Fax:815-784-5189
Practice Address - Street 1:109 S GENOA ST
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:IL
Practice Address - Zip Code:60135-1120
Practice Address - Country:US
Practice Address - Phone:815-784-5188
Practice Address - Fax:815-784-5189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL724210Medicare ID - Type Unspecified
ILC42656Medicare UPIN